Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC RESP VIRUS PANEL NUCLEIC ACID

Facility

$464.00

Service Code	CPT 87633
Hospital Charge Code	900912337
Hospital Revenue Code	306
Min. Negotiated Rate	$255.20
Max. Negotiated Rate	$416.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$278.40
Rate for Payer: Aetna of CA Government/Medicare	$278.40
Rate for Payer: Cash Price	$208.80
Rate for Payer: Cash Price	$208.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$371.20
Rate for Payer: Health Smart Auto/Commercial	$278.40
Rate for Payer: Intervalley Health Plan Commercial	$416.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$278.40
Rate for Payer: LLUH Dept of Risk Management WC	$255.20
Rate for Payer: Multiplan Commercial	$348.00

HC RETICULOCYTE COUNT, AUTO

Facility

$40.00

Service Code	CPT 85046
Hospital Charge Code	900910088
Hospital Revenue Code	305
Min. Negotiated Rate	$5.57
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.00
Rate for Payer: Aetna of CA Government/Medicare	$24.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.00
Rate for Payer: Health Smart Auto/Commercial	$24.00
Rate for Payer: Intervalley Health Plan Commercial	$5.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.00
Rate for Payer: LLUH Dept of Risk Management WC	$22.00
Rate for Payer: Multiplan Commercial	$30.00

HC RETICULOCYTE COUNT, AUTO

Facility

$104.00

Service Code	CPT 85046
Hospital Charge Code	900910088
Hospital Revenue Code	305
Min. Negotiated Rate	$57.20
Max. Negotiated Rate	$83.20
Rate for Payer: Cash Price	$46.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.20
Rate for Payer: Health Smart Auto/Commercial	$62.40
Rate for Payer: LLUH Dept of Risk Management WC	$57.20
Rate for Payer: Multiplan Commercial	$78.00

HC RETICULOCYTE COUNT, MANUAL

Facility

$23.00

Service Code	CPT 85044
Hospital Charge Code	900910063
Hospital Revenue Code	305
Min. Negotiated Rate	$4.31
Max. Negotiated Rate	$18.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.80
Rate for Payer: Aetna of CA Government/Medicare	$13.80
Rate for Payer: Cash Price	$10.35
Rate for Payer: Cash Price	$10.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: Intervalley Health Plan Commercial	$4.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Commercial	$17.25

HC RETICULOCYTE COUNT, MANUAL

Facility

$124.00

Service Code	CPT 85044
Hospital Charge Code	900910063
Hospital Revenue Code	305
Min. Negotiated Rate	$68.20
Max. Negotiated Rate	$99.20
Rate for Payer: Cash Price	$55.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$99.20
Rate for Payer: Health Smart Auto/Commercial	$74.40
Rate for Payer: LLUH Dept of Risk Management WC	$68.20
Rate for Payer: Multiplan Commercial	$93.00

HC RHEUMATOID FACTOR

Facility

$58.00

Service Code	CPT 86431
Hospital Charge Code	900910868
Hospital Revenue Code	302
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$46.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$34.80
Rate for Payer: Aetna of CA Government/Medicare	$34.80
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cash Price	$26.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$46.40
Rate for Payer: Health Smart Auto/Commercial	$34.80
Rate for Payer: Intervalley Health Plan Commercial	$5.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$34.80
Rate for Payer: LLUH Dept of Risk Management WC	$31.90
Rate for Payer: Multiplan Commercial	$43.50

HC RHEUMATOID FACTOR

Facility

$170.00

Service Code	CPT 86431
Hospital Charge Code	900910868
Hospital Revenue Code	302
Min. Negotiated Rate	$93.50
Max. Negotiated Rate	$136.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$136.00
Rate for Payer: Health Smart Auto/Commercial	$102.00
Rate for Payer: LLUH Dept of Risk Management WC	$93.50
Rate for Payer: Multiplan Commercial	$127.50

HC RIBS BILATERAL

Facility

$1,577.00

Service Code	CPT 71110
Hospital Charge Code	909001425
Hospital Revenue Code	320
Min. Negotiated Rate	$867.35
Max. Negotiated Rate	$1,261.60
Rate for Payer: Cash Price	$709.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,261.60
Rate for Payer: Health Smart Auto/Commercial	$946.20
Rate for Payer: LLUH Dept of Risk Management WC	$867.35
Rate for Payer: Multiplan Commercial	$1,182.75

HC RIBS BILATERAL

Facility

$1,577.00

Service Code	CPT 71110
Hospital Charge Code	909001425
Hospital Revenue Code	320
Min. Negotiated Rate	$867.35
Max. Negotiated Rate	$1,261.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$946.20
Rate for Payer: Aetna of CA Government/Medicare	$946.20
Rate for Payer: Cash Price	$709.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,261.60
Rate for Payer: Health Smart Auto/Commercial	$946.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$946.20
Rate for Payer: LLUH Dept of Risk Management WC	$867.35
Rate for Payer: Multiplan Commercial	$1,182.75

HC RIBS UNILATERAL

Facility

$1,240.00

Service Code	CPT 71100
Hospital Charge Code	909001376
Hospital Revenue Code	320
Min. Negotiated Rate	$682.00
Max. Negotiated Rate	$992.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$744.00
Rate for Payer: Aetna of CA Government/Medicare	$744.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$992.00
Rate for Payer: Health Smart Auto/Commercial	$744.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$744.00
Rate for Payer: LLUH Dept of Risk Management WC	$682.00
Rate for Payer: Multiplan Commercial	$930.00

HC RIBS UNILATERAL

Facility

$1,240.00

Service Code	CPT 71100
Hospital Charge Code	909001376
Hospital Revenue Code	320
Min. Negotiated Rate	$682.00
Max. Negotiated Rate	$992.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$992.00
Rate for Payer: Health Smart Auto/Commercial	$744.00
Rate for Payer: LLUH Dept of Risk Management WC	$682.00
Rate for Payer: Multiplan Commercial	$930.00

HC ROOM DETOX

Facility

$5,100.00

Hospital Charge Code	902302115
Hospital Revenue Code	126
Min. Negotiated Rate	$988.00
Max. Negotiated Rate	$3,825.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$988.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,011.00
Rate for Payer: Health Smart Auto/Commercial	$1,107.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,805.00
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,350.61
Rate for Payer: Multiplan Commercial	$3,825.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,014.26

HC ROOM DETOX ADOLESCENT

Facility

$5,100.00

Hospital Charge Code	902322115
Hospital Revenue Code	126
Min. Negotiated Rate	$988.00
Max. Negotiated Rate	$3,825.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$988.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,011.00
Rate for Payer: Health Smart Auto/Commercial	$1,107.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,805.00
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,350.61
Rate for Payer: Multiplan Commercial	$3,825.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,014.26

HC ROOM DETOX ADULT

Facility

$5,100.00

Hospital Charge Code	902301115
Hospital Revenue Code	126
Min. Negotiated Rate	$988.00
Max. Negotiated Rate	$3,825.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$988.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,011.00
Rate for Payer: Health Smart Auto/Commercial	$1,107.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,805.00
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,350.61
Rate for Payer: Multiplan Commercial	$3,825.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,014.26

HC ROOM DETOX CHILD

Facility

$5,100.00

Hospital Charge Code	902304115
Hospital Revenue Code	126
Min. Negotiated Rate	$988.00
Max. Negotiated Rate	$3,825.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$988.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,011.00
Rate for Payer: Health Smart Auto/Commercial	$1,107.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,805.00
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,350.61
Rate for Payer: Multiplan Commercial	$3,825.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,014.26

HC ROOM DETOX GERIATRIC

Facility

$5,100.00

Hospital Charge Code	902303115
Hospital Revenue Code	126
Min. Negotiated Rate	$988.00
Max. Negotiated Rate	$3,825.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$988.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Cash Price	$2,295.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,011.00
Rate for Payer: Health Smart Auto/Commercial	$1,107.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,805.00
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,350.61
Rate for Payer: Multiplan Commercial	$3,825.00
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,014.26

HC ROOM ICU PSYCH ADOLESCENT

Facility

$5,559.00

Hospital Charge Code	902301136
Hospital Revenue Code	204
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$4,447.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00
Rate for Payer: Aetna of CA Government/Medicare	$1,112.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$981.00
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,447.20
Rate for Payer: Health Smart Auto/Commercial	$1,154.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,057.45
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,407.43
Rate for Payer: Multiplan Commercial	$4,169.25
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,098.28

HC ROOM ICU PSYCH ADULT

Facility

$5,049.00

Hospital Charge Code	902301116
Hospital Revenue Code	204
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$4,039.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00
Rate for Payer: Aetna of CA Government/Medicare	$1,112.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$981.00
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,039.20
Rate for Payer: Health Smart Auto/Commercial	$1,154.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,776.95
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,407.43
Rate for Payer: Multiplan Commercial	$3,786.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,098.28

HC ROOM ICU PSYCH CHILD

Facility

$5,559.00

Hospital Charge Code	902301126
Hospital Revenue Code	204
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$4,447.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00
Rate for Payer: Aetna of CA Government/Medicare	$1,112.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$981.00
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Cash Price	$2,501.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,447.20
Rate for Payer: Health Smart Auto/Commercial	$1,154.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: LLUH Dept of Risk Management WC	$3,057.45
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,407.43
Rate for Payer: Multiplan Commercial	$4,169.25
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,098.28

HC ROOM ICU PSYCH GERIATRIC

Facility

$5,049.00

Hospital Charge Code	902301125
Hospital Revenue Code	204
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$4,039.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00
Rate for Payer: Aetna of CA Government/Medicare	$1,112.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$981.00
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Cash Price	$2,272.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,039.20
Rate for Payer: Health Smart Auto/Commercial	$1,154.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,776.95
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,407.43
Rate for Payer: Multiplan Commercial	$3,786.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,098.28

HC ROOM INTENSIVE ADOL EATING DIS

Facility

$2,338.00

Hospital Charge Code	902301138
Hospital Revenue Code	204
Min. Negotiated Rate	$981.00
Max. Negotiated Rate	$1,870.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,112.00
Rate for Payer: Aetna of CA Government/Medicare	$1,112.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$1,100.00
Rate for Payer: Blue Shield of California Commercial	$981.00
Rate for Payer: Cash Price	$1,052.10
Rate for Payer: Cash Price	$1,052.10
Rate for Payer: Cash Price	$1,052.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1,870.40
Rate for Payer: Health Smart Auto/Commercial	$1,154.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal/Medicare Advantage	$1,064.00
Rate for Payer: Intervalley Health Plan Commercial	$1,170.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,285.90
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,407.43
Rate for Payer: Multiplan Commercial	$1,753.50
Rate for Payer: US Behavioral Health Commercial/Medicare	$1,098.28

HC ROOM REHAB

Facility

$1,849.00

Hospital Charge Code	902301114
Hospital Revenue Code	128
Min. Negotiated Rate	$882.00
Max. Negotiated Rate	$1,450.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$882.00
Rate for Payer: Aetna of CA Government/Medicare	$882.00
Rate for Payer: Beacon Health Medi-Cal/Medicare Advantage	$975.00
Rate for Payer: Blue Shield of California Commercial	$1,006.00
Rate for Payer: Cash Price	$832.05
Rate for Payer: Cash Price	$832.05
Rate for Payer: Cash Price	$832.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$885.00
Rate for Payer: Health Smart Auto/Commercial	$884.00
Rate for Payer: Intervalley Health Plan Commercial	$1,070.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,039.00
Rate for Payer: LLUH Dept of Risk Management WC	$1,016.95
Rate for Payer: Magellan Commercial	$1,450.00
Rate for Payer: Mary Free Bed Workers' Compensation	$1,041.37
Rate for Payer: Multiplan Commercial	$1,386.75
Rate for Payer: US Behavioral Health Commercial/Medicare	$921.84

HC ROTOVIRUS AG

Facility

$39.00

Service Code	CPT 87425
Hospital Charge Code	900910976
Hospital Revenue Code	306
Min. Negotiated Rate	$11.98
Max. Negotiated Rate	$31.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.40
Rate for Payer: Aetna of CA Government/Medicare	$23.40
Rate for Payer: Cash Price	$17.55
Rate for Payer: Cash Price	$17.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.20
Rate for Payer: Health Smart Auto/Commercial	$23.40
Rate for Payer: Intervalley Health Plan Commercial	$11.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.40
Rate for Payer: LLUH Dept of Risk Management WC	$21.45
Rate for Payer: Multiplan Commercial	$29.25

HC ROTOVIRUS AG

Facility

$172.00

Service Code	CPT 87425
Hospital Charge Code	900910976
Hospital Revenue Code	306
Min. Negotiated Rate	$94.60
Max. Negotiated Rate	$137.60
Rate for Payer: Cash Price	$77.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$137.60
Rate for Payer: Health Smart Auto/Commercial	$103.20
Rate for Payer: LLUH Dept of Risk Management WC	$94.60
Rate for Payer: Multiplan Commercial	$129.00

HC ROUTINE URINALYSIS

Facility

$135.00

Service Code	CPT 81001
Hospital Charge Code	900910167
Hospital Revenue Code	307
Min. Negotiated Rate	$74.25
Max. Negotiated Rate	$108.00
Rate for Payer: Cash Price	$60.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.00
Rate for Payer: Health Smart Auto/Commercial	$81.00
Rate for Payer: LLUH Dept of Risk Management WC	$74.25
Rate for Payer: Multiplan Commercial	$101.25

Know your out-of-pocket cost for care.

All Charges